Beruflich Dokumente
Kultur Dokumente
LIVING (OLTL)
HOME AND COMMUNITYBASED SERVICES (HCBS)
PROVIDER HANDBOOK
January 2014
TABLE OF CONTENTS
Introduction
Chapter 1
DEPARTMENT OF PUBLIC WELFARE (DPW)
Organization ...........................................................................................................................3
Office of Long-Term Living (OLTL) ..........................................................................................3
Chapter 2
OLTL WAIVERS AND PROGRAMS
Waiver and Act 150 Services ..................................................................................................6
Service Coordination ............................................................................................................. 10
Organized Health Care Delivery System (OHCDS) ............................................................... 12
Nursing Home Transition (NHT) ............................................................................................ 12
Money Follows the Person (MFP) ......................................................................................... 13
Living Independence for the Elderly (LIFE) ........................................................................... 15
Financial Management Services (FMS) ................................................................................ 16
Services My Way (SMW) ...................................................................................................... 17
Chapter 3
PARTICIPANT ELIGIBILITY AND SERVICE PLANNING
Home and Community-Based Services Individual Service Plan (HCBS ISP) ........................ 20
Service Coordination Entity (SCE) Responsibilities ............................................................... 24
Participant Record Specifications .......................................................................................... 24
Independent Enrollment Broker (IEB).................................................................................... 25
Recipient Restriction/Centralized Lock-In Program ............................................................... 26
Managed Care ...................................................................................................................... 27
Chapter 4
PROVIDER INFORMATION
Provider Enrollment .............................................................................................................. 31
Medicheck (Precluded Providers) List. .................................................................................. 33
Provider Eligibility. ................................................................................................................. 35
Billing Guidelines .................................................................................................................. 35
Provider Access to Service Authorizations (PASA) ............................................................... 40
Chapter 5
QUALITY MANAGEMENT
Bureau of Quality and Provider Management & QMET Monitoring ........................................ 42
Bureau of Program Integrity .................................................................................................. 43
Chapter 6
SYSTEMS
Home and Community Services Information System (HCSIS) .............................................. 46
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Appendix A:
Regulations
(A)(1) 1101 General Provisions .......................................................................................... 53
(A)(2) 52 Long-Term Living Home and Community-Based Services .................................. 54
(A)(3) 611 Home Care Agencies and Home Care Registries.............................................. 55
(A)(4) 41 Medical Assistance Provider Appeal Procedures ................................................ 56
(A)(5) 1150 MA Program Payment Policies ........................................................................ 57
Appendix B:
Policy
(B)(1) Bulletin List (OLTL) ..................................................................................................... 58
(B)(2) FAQs .......................................................................................................................... 59
(B)(3) HCBS Eligibility/Ineligibility/Change Form (PA 1768) .................................................. 60
Appendix C:
Provider Forms
(C)(1) OLTL Individual Service Plan ...................................................................................... 65
(C)(2) New Participant Web Portal Referral CHECK LIST ..................................................... 69
(C)(3) New Participant F/EA FMS Interim Referral Form ....................................................... 71
(C)(4) Freedom of Choice Form ............................................................................................ 72
(C)(5) Service Provider Choice Form .................................................................................... 74
(C)(6) OLTL Service Authorization Form (MA 560) ............................................................... 78
(C)(7) Notice of Service Determination and the Right to Appeal (MA 561) ............................ 80
(C)(8) Bureau of Hearings and Appeals (BHA) Agency Appeal Cover Sheet ........................ 84
(C)(9) Decision to Withdraw an Appeal Request (MA 562) .................................................... 85
(C)(10) PROMISe Provider Enrollment Base Application CHECK LIST ................................ 86
(C)(11) PROMISe Provider Enrollment Base Application ...................................................... 88
(C)(12) HCBS Waiver Provider Agreement ......................................................................... 102
(C)(13) Provider Enrollment Form: COMMCARE, Independence & OBRA.......................... 104
(C)(14) Provider Enrollment Form: Aging Waiver ................................................................ 106
(C)(15) Provider Enrollment Form: Attendant Care & Act 150 ............................................. 108
(C)(16) Provider Enrollment Form: Service Coordination .................................................... 109
(C)(17) Provider Enrollment Form: OHCDS ........................................................................ 110
(C)(18) Provider Disclosure Form ....................................................................................... 112
(C)(19) Ordering Forms....................................................................................................... 121
Appendix D:
Reference & Resources
(D)(1) County Assistance Offices (CAO) Contact List ......................................................... 123
(D)(2) Area Agencies on Aging Map.................................................................................... 124
(D)(3) Health Insurance Portability and Accountability Act (HIPAA)..................................... 125
(D)(4) Eligibility Verification System Quick Tips ................................................................... 130
(D)(5) Recipient Benefits ..................................................................................................... 132
(D)(6) Utilizing Provider Resources ..................................................................................... 133
(D)(7) Rate Chart Fee Schedule Rates ............................................................................ 137
(D)(8) Rate Regions (4)....................................................................................................... 138
(D)(9) Crosswalk ................................................................................................................. 140
(D)(10) Remittance Advice Sample ..................................................................................... 154
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Appendix E:
Glossary ............................................................................................................................. 156
Appendix F:
Acronym List ....................................................................................................................... 162
January 2014
Introduction
The intent of this document is to be a reference manual for home and community-based
service providers. It is to be used as a reference tool to assist in the day-to-day operations in
the delivery of long-term care services. It does not take the place of existing policy and is not a
standalone policy document. It is to be used for reference to access more detailed
information on regulations and procedures required of the service provider network.
Published OLTL regulations, bulletins and procedures remain the paramount guidance that
service providers must follow and are the source documents on which this operational
reference document has been developed. Providers must also follow specific licensure
regulations and applicable local, state and federal laws. This manual does not supersede or
replace regulations or policies. In addition, if this manual is in conflict with a regulation or
policy, the regulations and policy supersede this manual.
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Chapter 1
DEPARTMENT OF PUBLIC WELFARE
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Chapter 1
DEPARTMENT OF PUBLIC WELFARE
Organization
The Department of Public Welfare consists of six executive level offices and seven different
program offices. All of the offices are listed below. To learn more about each program office
please explore the links below.
If you are looking to contact the Department, please email at
http://www.dpw.state.pa.us/Feedback/index.htm or call the Helpline at 1-800-692-7462.
Executive Offices:
Program Offices:
To see the most recent version and links to information on each of the Departments
individual offices, click
http://www.dpw.state.pa.us/dpworganization/index.htm
The majority of people who come to us for services will need assistance with daily activities,
such as bathing, dressing and meal preparation, at some point in their lives, whether due to
aging, injury, illness or disability. Knowing what types of services are needed, available and
how to obtain them is not easy. Services and supports available through the Pennsylvania
Office of Long-Term Living (OLTL) can assist eligible individuals.
The Office of Long-Term Living helps Pennsylvanians find answers to these questions:
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Providers may find assistance by calling the toll-free Provider Call Center at 1-800-932-0939.
Information about services is available at 1-866-286-3636. Counselors will be able to provide
information and refer you to the local agencies that can provide assistance with planning and
arranging long-term care and services.
Learn More
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Chapter 2
OLTL WAIVERS AND PROGRAMS
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Chapter 2
OLTL WAIVERS AND PROGRAMS
The following chart describes each of the HCBS programs that OLTL administers. Additional
details on eligibility criteria and the services available in each waiver may be found in
Appendices B and C of the waivers, respectively.
Program Description
Eligibility Criteria
Services Available
Aging Waiver
Program provides home
and community-based
services to eligible
persons age 60 or older
who are clinically
eligible for nursing
facility care.
Accessibility
Adaptations, Equipment,
Technology and Medical
Supplies
Adult Daily Living
Services
Community Transition
Services
Financial Management
Services
Home Delivered Meals
Home Health Services
Non-Medical
Transportation
Participant-Directed
Community Supports
Participant-Directed
Goods and Services
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Program Description
Eligibility Criteria
Services Available
Personal Assistance
Program Description
Eligibility Criteria
Services
Personal Emergency
Response System
(PERS)
Respite
Service Coordination
TeleCare
Therapeutic and
Counseling Services
Services Available
AIDS Waiver
Program provides home
and community-based
services to eligible
persons age 21 or older
who have symptomatic
HIV Disease or AIDS.
Program Description
Eligibility Criteria
Services Available
Community Transition
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Program Description
Eligibility Criteria
Services Available
COMMCARE Waiver
Program provides home
and community-based
services for individuals
with a medically
determined diagnosis of
traumatic brain injury
(TBI). COMMCARE
prevents the
institutionalization of
individuals with TBI and
helps them to remain as
independent as
possible.
Program Description
Eligibility Criteria
Services Available
Independence Waiver
Program provides
HCBS for persons with
physical disabilities to
allow them to live in the
community and remain
as independent as
possible. Also provides
services to people
dependent on medical
technology (required to
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self-care, self-direction,
independent living, and learning
Cannot have an intellectual
disability or a major mental disorder
as a primary diagnosis
Requires a nursing facility level of
care
Financial Management
Program Description
Eligibility Criteria
Services
Home Health
Non-Medical
Transportation
Personal Assistance
Services
Personal Emergency
Response System
(PERS)
Respite
Service Coordination
Supported Employment
Therapeutic and
Counseling Services
Services Available
OBRA Waiver
Home and communitybased services to
people with
developmental physical
disabilities to allow them
to live in the community
and remain as
independent as
possible.
Adaptations, Equipment,
Technology and Medical
Supplies
Community Integration
Community Transition
Services
Financial Management
Services
Home Health
Non-Medical
Transportation
Personal Assistance
Services
Personal Emergency
Response System
(PERS)
Prevocational Services
Residential Habilitation
Services
Respite
Service Coordination
Structured Day
Habilitation Services
Supported Employment
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Therapeutic and
Counseling Services
Service Coordination
Service Coordinators (SCs) perform the following core functions in assuring the quality of an
HCBS waiver service plan:
Assessment (Care Management Instrument): Conduct an accurate evaluation of a
participants strengths, needs, preferences, supports and desired outcomes.
Service plan development: Work with participants to design and modify a service plan that
enables them to meet their needs, preferences and goals.
Referral: Provide information to help participants choose qualified providers and make
arrangements to assure providers follow the service plan.
Note: SCs are to distribute the Standardized HCBS Waiver Participant Informational
Materials to participants at the time of their annual redeterminations, which can be found
at:
http://www.dpw.state.pa.us/publications/bulletinsearch/bulletinsearchresults/index.htm?po
=OLTL.
Monitoring: Ensure that participants get authorized services and that services meet
individual needs and goals.
Remediation: Resolve problems when something goes wrong as well as anticipate the
potential for problems.
In addition to the important work SCs do to promote quality directly with participants, they
have an equally important role in documenting the work they do.
Good documentation:
The information SCs provide through their documentation not only provides evidence that SCs
are meeting the assurances, it also affects future services.
For further information, please refer to the Service Coordination service definition in the
waivers, for example, in the Aging or Attendant Care waivers; also reference 55 Pa. Code
Chapter 52.
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CMS has recommended the use of an Organized Health Care Delivery System
(OHCDS) model to states in order to ensure compliance with provider agreements and
direct payment requirements.
This arrangement is used by some OLTL providers. Only certain services can be
provided under the OHCDS model. They are: Accessibility Adaptations; Community
Transition Services; Durable Medical Equipment and Supplies; Home Delivered Meals;
Non-Medical Transportation; and Personal Emergency Response System (PERS).
OLTL has developed an OHCDS Provider Enrollment Form that allows AAAs and
other provider organizations to continue intermediary billing as an OHCDS and comply
with federal requirements.
For further information, please see 55 Pa. Code Chapter 51.141 and Chapter 52.53.
Also reference Appendix (C)(15) for OHCDS Provider Enrollment Form.
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The NHT program was developed to assist and empower consumers who want to move from
a nursing facility back to a home of their choice in the community and to help the
Commonwealth rebalance its long-term living systems so that people have a choice of where
they live and receive services. The NHT program provides the opportunity for individuals and
their families or caregivers to be fully informed of all long-term living options, including the full
range of home and community-based services. Individuals interested in transitioning receive
the guidance and support needed to make an informed choice about their long-term living
services. The program assists individuals in moving out of institutions and eliminating barriers
in service systems so that individuals receive services and supports in settings of their choice.
Goals and Objectives of the NHT Program: To help rebalance the long-term living system
so that people have a choice of where they live and receive services. The program:
If someone resides in a nursing facility and would like to return home, support exists that can
make that happen. There are Home and Community-Based Services available to help with
daily living needs. Local Area Agencies on Aging, Centers for Independent Living or disability
service organizations can provide information about additional resources. These resources
can be used to pay for the necessary expenses to establish basic living arrangements and
help individuals move into the community. Agencies may also help to locate housing, assist
with home modifications and arrange for in-home care.
Please note that the Area Agency on Aging (AAA) serves individuals 60 years of age and over
and individuals under the age of 60 are served by a Center for Independent Living or a
disability service organization. When calling the agency, please ask to speak to the nursing
home transition staff.
MFP is a federal initiative that will provide assistance to people who live in institutions
so they can return to their own communities to live independently.
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It is an opportunity for states, along with advocates, family members and loved ones to
join together so individuals can live as independently as possible.
The MFP initiative focuses on a number of different groups of people, including the
elderly, individuals with physical disabilities, people with developmental disability as
well as people with mental illness.
It is an initiative that will bring more federal dollars into the state that can then be used
to help additional people return to their communities. It will provide additional federal
funding for Pennsylvanias Home and Community-Based Waiver Services (HCBS).
It is historic because it is the largest single investment in Home and Community-Based
Long-Term Living Services ever offered by the federal Centers for Medicare and
Medicaid Services.
Forty-two states and the District of Columbia have implemented MFP Programs. From
spring 2008 through December 2011, nearly 20,000 people have transitioned back into
the community through MFP Programs.
The Affordable Care Act of 2010 strengthens and expanded the Money Follows the
Person Program to more states. It extends the MFP Program through September 30,
2016, and appropriates an additional $2.25 billion ($450 million for each FY 20122016).
Have resided in a nursing facility, Intermediate Care Facility for Mental Retardation
(ICF/MR) or state hospital for at least 90 days;
Be actively receiving Medical Assistance or Medicaid benefits for at least 1 day prior to
discharge/transition;
Be transitioning to a Qualified Residence, defined by federal government as:
o A home owned or leased by the individual or the individuals family member;
o An apartment with an individual lease that has lockable doors (inside and out),
and which includes living, sleeping, bathing and cooking areas over which the
individual or the individuals family has control;
o A residence, in a community-based residential setting, in which no more than
four unrelated individuals reside.
Meet the eligibility criteria for one of the following state Home and Community-Based
waiver programs or the LIFE program:
Aging Waiver
Independence Waiver
OBRA Waiver
LIFE
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Choose the qualified residence in which they will reside and the setting in which they
will receive home and community-based services and supports. Professional staff will
be available to assist participants locate and secure a residence in the community.
Services Provided
This initiative builds upon existing services, supports and transitional efforts offered through
the following Department of Public Welfare program offices:
Office of Developmental Programs
Office of Long-Term Living
Office of Mental Health and Substance Abuse Services
To get more information about Money Follows the Person contact the Office of Policy
Development at 1-800-692-7462.
Be age 55 or older
Meet the level of care needs for a Nursing Facility or a Special Rehabilitation Facility
Meet the financial requirements as determined by your local County Assistance Office
or able to private pay
Reside in an area served by a LIFE provider
Be able to be safely served in the community as determined by a LIFE provider
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employment taxes and locality taxes, processing direct care worker timesheets, brokering
workers compensation insurance policies, and preparing and distributing financial reports.
A VF/EA FMS operates in accordance with 3504 of the IRS code, IRS Revenue Procedure
70-6, IRS Proposed Notice 2003-70 and REG-137036-08, as applicable.
In Pennsylvania, the fiscal support services provided by a VF/EA FMS organization include,
but are not limited to:
1. Acting as a neutral bank for individuals public service funds;
2. Ensuring qualified direct care workers (DCWs) and vendors are paid in accordance with
federal, state and local tax, labor and unemployment insurance laws, as applicable;
3. Preparing and distributing qualified DCWs payroll including processing DCWs timesheets
and the management of federal and state income tax withholding and employment taxes and
locality taxes;
4. Verifying prospective DCWs and vendors, citizenship and alien status and ensuring that
DCWs and vendors meet the qualifications for the services they are providing as per state
requirements (this includes screening candidates through the precluded participation lists);
5. Processing and paying invoices for participant-directed goods and services in accordance
with the participants individual service plan (ISP) and spending plan;
6. Processing and submitting claims and receiving Medical Assistance (MA) reimbursements
and paying out for services provided by qualified DCWs and vendors in accordance with the
participants ISP;
7. Brokering workers compensation insurance policies and renewals and paying premiums for
individuals and representatives who are common law employers;
8. Preparing and distributing financial reports to: common law employers, Service
Coordinators and OLTL as required; and
9. Providing orientation and skills training to individuals and representative acting as common
law employers.
In 2013, the Office of Long-Term Living procured FMS to a single agency. For more
information and updates on the transition, go to the OLTL website at:
http://www.dpw.state.pa.us/dpworganization/officeoflongtermliving/providers/index.htm, or to
the VF/EAs site at https://www.publicpartnerships.com.
Also reference Appendix (C)(2) for New Participant Web Portal Referral CHECK LIST and
Appendix (C)(3) New Participant F/EA FMS Interim Referral Form.
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services. Under this model, participants have the opportunity to: 1) select and manage staff
that perform personal assistance type services under the Participant-Directed Community
Supports service definition; 2) manage a flexible spending plan; and 3) purchase allowable
goods and services through their spending plan. Under Services My Way, the
participant/representative is the common-law employer of the service and support workers
who they directly hire.
Participants will receive a full-range of supports, ensuring that they are successful with the
participant-directed experience. Individuals choosing the SMW model will receive support from
the certified VF/EA and service coordinators to assist them in their role as the common-law
employer of their workers. The F/EA will:
1. Complete all necessary payroll and employment forms
2. Withhold, file and pay payroll and employment taxes
3. Process and disburse payroll
4. Broker and process payment for workers compensation on behalf of the participant
5. Certify and enroll individual providers
6. Provide training to participant on recruiting, interviewing, hiring, training, managing,
and/or dismissing workers
7. Monitor spending of the spending plan
In addition, OLTL authorized service coordinators to assist in the development of each
participants spending plan. The spending plan is based on: the individuals level of care
assessment, the individual service plan, budget development and the spending plan
developed by the participant. Once the spending plan is developed, authorized and approved
by OLTL, the participant is responsible for arranging and directing the services outlined in their
plan. During the implementation and management of the spending plan, the service
coordinator will:
1. Advise, train, and support the participant as needed and necessary
2. Assist with the execution and development of the spending plan
3. Assist the participant to develop an emergency back-up plan
4. Identify risks or potential risks and develop a plan to manage those risks
5. Monitor expenditures of the spending plan
6. Monitor the participants health and welfare
7. Assist the participant to secure training of support workers who deliver services
8. Assist the participant to gain information and access to necessary services,
regardless of the funding sources
Services My Way gives choice to waiver participants and improves their individual
opportunities for full participation in the community. This is done by living independently in
their homes, while providing for their health and safety at a cost no greater than traditional
services.
SMW overview information can be found under the Aging and Attendant Care Waivers at:
http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/supportserviceswaivers/ind
ex.htm.
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Chapter 3
PARTICIPANT ELIGIBILITY AND SERVICE PLANNING
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Chapter 3
PARTICIPANT ELIGIBILITY AND SERVICE PLANNING
If a participant has applied for Medical Assistance, the results of the clinical eligibility (LOCA)
indicating that the participant is clinically eligible is forwarded to the local County Assistance
Office (CAO) for financial eligibility determination. Waiver services may only be delivered after
the participant has been determined both clinically and financially eligible and an approved
individual service plan is in place. For information on the CAOs and applying for benefits, refer
to: http://www.dpw.state.pa.us/applyforbenefits/index.htm.
The SCE will receive the needs assessment from the Independent Enrollment Broker (except
for those participants applying for Aging Waiver services, whose LOCA and needs
assessment are both completed by the AAA). The needs assessment may be pre-populated
with common data from the LOCA. The Independent Enrollment Broker is a contracted
statewide entity to facilitate and streamline the eligibility/enrollment process for applicants
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seeking services for several Pennsylvania waivers/programs. For more information, refer to
the Independent Enrollment Broker section below.
The HCBS ISP must be developed so every participant has an individualized plan. The
provider of service will be required to implement and provide HCBS to the participant in the
type, scope, amount, duration and frequency as specified in the HCBS ISP.
(A) Every participant in an HCBS program shall have an individualized HCBS ISP.
(B) The HCBS ISP will contain:
(1) The participants needs.
(2) The participants goals.
(3) The participants outcomes.
(4) The HCBS, third party payer, and informal supports meeting the participants needs,
goal or outcome.
(5) The type, scope, amount, duration and frequency of HCBS needed by the participant.
(6) The provider of each HCBS.
(7) A participant signature.
(8) Risk mitigation strategies.
(9) Back-up plan.
(i) The back-up plan must contain an individualized back-up plan and an emergency
back-up plan based on the individuals preferences.
(ii) The individualized back-up plan must outline the steps to be taken to ensure the
delivery of HCBS in the case that routine HCBS are not able to be delivered.
(iii) The emergency back-up plan must outline steps to be taken to ensure the delivery
of HCBS in the case of serious emergencies that cause a disruption of HCBS
delivery.
(C) Each identified need must be addressed by an informal support, third party payer or
HCBS.
(D) The following HCBS require a physicians prescription prior to be added to the HCBS ISP:
(1) Physical therapy.
(2) Occupational therapy.
(3) Speech and language therapy.
(4) Nursing services.
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The SCE completes all of the information on the HCBS ISP form based on the SCE
responsibilities listed above.
The SCE supervisor reviews and submits the HCBS ISP to the Department.
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In the event that the SCE or the Department denies, reduces, terminates, or suspends
services, the SCE will provide the participant the reason(s) for the denial in writing using the
Notice of Service Determination and the Right to Appeal MA 561 Form. See Appendix (C)(7).
Please refer to the Hearings and Appeals Bulletin for additional information:
http://www.dpw.state.pa.us/publications/bulletinsearch/bulletinselected/index.htm?bn=51-1312&o=N&po=OLTL&id=12/23/2013.
Note: Federal requirements mandate that eligibility determinations be made within 90 days.
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SCE Responsibilities
1. Schedule a face-to-face meeting to develop an initial HCBS ISP with the participant
within five (5) business days of receiving the participants completed information,
including the LOCA and needs assessment.
2. Coordinate services and supports with all third-party payers, formal and informal
supports, and other community resources to assure that funding sources through the
HCBS waiver are the payer of last resort and that there is no duplication of services.
The SCE must document and justify the purchase of the service or product and
attempts to obtain or purchase through other resources (private insurance, Medicare,
State Plan and any other local resources available).
3. Authorize services or a combination of services selected or desired by the participant
or the representative only when the participants physical, cognitive, or emotional
condition and overall activities of daily living (ADL) and instrumental activities of daily
living (IADL) functioning require the service(s) to improve or maintain his or her
functioning and/or condition.*
4. Implement and monitor the HCBS ISP consistent with timeframes and requirements of
the waiver or Act 150 program.
5. Review and update the HCBS ISP at least annually within the re-evaluation due date
and if the participants needs change.
*Please refer to the OLTL Service Authorization Form Bulletin for additional information:
http://www.dpw.state.pa.us/publications/bulletinsearch/bulletinselected/index.htm?bn=51-1307&o=N&po=OLTL&id=07/12/2013. A copy of the form can be found below at Appendix
(C)(6).
For more detailed information on SCE responsibilities within each waiver, visit DPWs website
at:
http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/supportserviceswaivers/ind
ex.htm.
Aging Waiver
AIDS Waiver
Attendant Care
Waiver/Act 150
COMMCARE Waiver
A copy of the physicians script obtained by the SC (not needed for the
Act 150 Program)
A copy of the recertification of the need for HCBS. For all waivers, a
LOCA and needs assessment must be completed at the initial
enrollment. During the annual reevaluation, a needs assessment must
Independence Waiver
LIFE Program
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OBRA Waiver
Eligibility/Enrollment Process
Participant eligibility determination is a multi-step process involving several agencies,
coordinated by the PA IEB. The final decision maker regarding participant eligibility is OLTL.
Eligibility Determination Process for AIDS, Attendant Care, COMMCARE, Independence
and OBRA waivers and Act 150 program:
The PA Independent Enrollment Broker (IEB) meets with the applicant and completes a
needs assessment
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The AAA and CAO may begin to review eligibility prior to receiving the physician
certification form
The individuals physician completes a physician certification form
The AAA completes a level of care assessment
The County Assistance Office completes the financial eligibility
OLTL determines program eligibility and enrolls the applicant or determines applicant not
eligible
Note: When communicating with the CAO regarding consumer eligibility for waiver services,
the Home and Community-Based Services (HCBS) Eligibility/Ineligibility/Change PA-1768
form should be filled out. This form should be used when a consumer is new, has changes or
is a transfer. Refer to Appendix (B)(3).
Contact:
To begin the participant eligibility/enrollment process, please contact the PA Independent
Enrollment Broker:
Toll free helpline: 877.550.4227
Toll free TTY line: 877.824.9346
Fax number: 717.540.6201
Address (for the central office in Harrisburg):
PA Independent Enrollment Broker
6385 Flank Drive, Suite 400
Harrisburg, PA 17112-4603
*For applicants age 60 and over, contact the local AAA for eligibility/enrollment services.
Note: The IEB and AAA enrollment staff are to distribute the Standardized HCBS Waiver
Participant Informational Materials to participants, which can be found at:
http://www.dpw.state.pa.us/publications/bulletinsearch/bulletinsearchresults/index.htm?po=OL
TL.
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services. DPW may not pay for a service rendered by any provider other than the one to
whom the recipient is restricted, unless the services are furnished in response to an
emergency or a Medical Assistance Recipient Referral Form (MA 45) is completed and
submitted with the claim. The MA 45 must be obtained from the practitioner to whom the
recipient is restricted.
A recipient placed in this program can be locked-in to any number of providers at one time.
Restrictions are removed after a period of five years if improvement in use of services is
demonstrated.
DPW is the only entity that sets the lock-in restrictions for recipient benefits. Specifically, the
Bureau of Program Integrity (BPI) is responsible for recipient reviews and restrictions.
If a recipient is restricted to a provider within a particular provider type, the EVS will notify that
provider if the recipient is locked into theirs or another provider. The EVS will also indicate all
type(s) of provider(s) to which the recipient is restricted.
For further information regarding violations, see 55 Pa. Code Chapter 1101.91-95 [Refer to
Appendix (A)(1) of this manual].
Note: Valid emergency services are excluded from the lock-in process.
Managed Care
HealthChoices General Information
http://www.dpw.state.pa.us/foradults/healthcaremedicalassistance/healthchoicesgeneralinform
ation/index.htm
The HealthChoices Program is the name of Pennsylvanias mandatory managed care
program for Medical Assistance recipients.
Through Physical Health Managed Care Organizations, recipients receive quality medical
care and timely access to all appropriate physical health services, whether the services are
delivered on an inpatient or outpatient basis. The Department of Public Welfare's Office of
Medical Assistance Programs oversees the Physical Health component of the HealthChoices
Program.
Through Behavioral Health Managed Care Organizations, recipients receive quality medical
care and timely access to appropriate mental health and/or drug and alcohol services. This
component is overseen by the Department of Public Welfare's Office of Mental Health and
Substance Abuse Services.
HealthChoices currently serves approximately 1,225,000 recipients in the following zones:
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New West Zone - Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson,
McKean, Mercer, Potter, Venango and Warren counties
New East Zone - Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna,
Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill,
Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming counties
The HealthChoices Program has three goals that guide the Department of Public Welfare in
its implementation efforts. These goals are:
External Users
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Chapter 4
PROVIDER INFORMATION
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January 2014
Chapter 4
PROVIDER INFORMATION
Provider Enrollment
In order for providers to participate in the Home and Community-Based Services Program,
they must first enroll. To be eligible to enroll, providers in Pennsylvania must be licensed and
currently registered by the appropriate state agency. Providers must be approved, licensed,
issued a permit or certified by the appropriate state agency, and if applicable certified under
Medicare. To enroll, providers must complete a Base Provider Enrollment form and any
applicable addenda documents based on the provider type.
Before completing and submitting an application it is important that a provider determine if it
qualifies to provide the services. A prospective provider must determine if it will be able to
comply with the Department (Title 55, Public Welfare, Chapters 1101, 1150 and 52) and CMS
rules and regulations.
It is critical that all required information is submitted with the application and provider
agreement. The Department will only review complete application packages. The Department
may request additional information from an applicant. Failure to comply with complete
applications or information requests will result in a voided application. A voided application will
occur after 30 days of receipt of the incomplete application. The Department will not return
voided materials.
The table below contains links to applicable provider enrollment forms for each provider type
and specialty. Print the documents for the appropriate provider type and specialty and follow
the instructions for completing the documents.
Any questions about completing any of the documents, can be addressed by calling the OLTL
Provider Call Center at 1-800-932-0939 and ask for the Certification and Enrollment Section.
All enrollment documents are in Adobe PDF format. A copy of Adobe Acrobat Reader must be
installed on any computer system to view them.
Additional Enrollment Forms - PROMISe Service Location Change Request and
Instructions
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55 - Vendor
* Aging Waiver
59 - Attendant Care
Provider
* includes Act 150
Service Coordination
Entity
Note: The Aging and AIDS waivers are enrolled using multiple provider types depending on
the service they are providing.
For further information reference:
http://www.dpw.state.pa.us/provider/promise/enrollmentinformation/index.htm
In this manual, reference Appendix (C) for copies of forms.
Once an application has been processed and approved and a PROMISe number has been
assigned, a newly enrolled provider will receive a computer generated enrollment letter from
PROMISe, which is the Departments claims processing system.
Any changes to the approved enrollment application must be reported to the Department. This
includes, but is not limited to, changes in name, email address, ownership, address, service
delivery, etc. The Department must be notified 30 days prior to the effective date of the
change. If circumstances prohibit a 30-day advance notice notification must be within 2
business days. Failure to provide notification may result in loss of reimbursement for each
service that was provided during the overdue period.
1-800-543-7633
Hours of operation: Monday
Friday, 7:00 AM 8 PM,
Saturday 10 AM 2 PM
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717-787-8091
Eligibility Verification
Provides verification of MA eligibility and plan
information
Provides ACCESS Plus recipient PCP
assignment information
1-800-766-5387
Hours of operation: 24 hours a
day, 7 days a week
1-800-932-0939
Hours of operation:
Monday Thursday, 9 AM - 12
PM & 1 PM - 4 PM
1-877-299-2918
Hours of operation: Monday
Friday, 7:30 AM-4:00 PM
1-800-248-2152 or 717-9754100
Hours of operation: Monday
Friday, 8:00 AM5:00 PM
1-866-444-1264
Hours of operation: Monday
Friday, 8 AM-5 PM
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MA Program. Under applicable law, the Department and managed care organizations will not
pay for any services prescribed, ordered, or rendered by the providers or individuals listed on
the Medicheck List, including services performed in an inpatient hospital or long-term care
setting. See 55 Pa. Code Chapters 1101.42(c) and 1101.77(c) [Refer to Appendix (A)(1) of
this manual]. In addition, subsequent to the effective date of the termination or preclusion, any
entity of which five percent (5%) or more is owned by a sanctioned provider or individual will
not be reimbursed for any items or services rendered to MA recipients. It is a providers
responsibility to utilize this on-line searchable listing to screen all employees and contractors
(both individuals and entities), at the time of hire or contracting; and, thereafter, on an ongoing
monthly basis to determine if they have been excluded from participation in the state and
federal health care programs.
What is the LEIE and EPLS databases, and why should providers use it in addition to
the Medicheck List?
The List of Excluded Individuals/Entities (LEIE), maintained by the Department of Health and
Human Services, Office of Inspector General (DHHS/OIG), is a database of all individuals or
entities (this would include SCEs operating in Pennsylvania) that have been excluded
nationwide from participation in any federal health care program, e.g., Medicaid and Medicare.
Pursuant to federal and state law, any individual or entity included on the LEIE is ineligible to
participate, either directly or indirectly, in the MA Program. The LEIE is easy to use and can
be searched and downloaded from the OIG's website at:
https://oig.hhs.gov/exclusions/index.asp. Although the Department makes its best efforts to
include all federally excluded individuals/entities who practice in Pennsylvania on the
Medicheck List, providers should also use the LEIE to ensure that the individual/entity is
eligible to participate in the MA Program. For the list on DPWs site see:
http://www.dpw.state.pa.us/publications/medichecksearch/index.htm.
The Excluded Parties List System (EPLS), maintained by the General Services Administration
(GSA), is a database that provides information about parties excluded from receiving Federal
contracts, certain subcontracts, and certain Federal financial and nonfinancial assistance and
benefits. Please visit https://www.sam.gov/portal/public/SAM/ for more information.
Are providers automatically reinstated in the Medical Assistance Program at the end of
a preclusion period?
No. In accordance with 55 Pa. Code Chapter 1101.82(a) [Refer to Appendix (A)(1) of this
manual], providers who have reached the end of their preclusion period must request and be
re-enrolled by the Department in order to participate.
How can a potential match be confirmed?
If, after searching The Medicheck list, a potential match is discovered on an individual or
entity, the Bureau of Program Integrity (the Bureau) can be contacted at 717-705-6872 to
assist in validating that match. Please note that the Bureau does not perform routine
screenings for providers or contracted agencies hired to perform such screenings. In order to
validate a potential match, the Bureau requests that a provider supply the following
information via email to RA-BPI-Preclusions@pa.gov.
The name of the individual or entity
Date of Birth
Last four digits of the potential matchs social security number
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Provider Eligibility
Eligibility Verification System
The Eligibility Verification System (EVS) enables providers to determine an MA recipients
eligibility as well as their scope of coverage. Please do not assume that the recipient is eligible
because he/she has an ACCESS card. It is vital that a provider verifies the recipients
eligibility through EVS each time the recipient is seen. EVS should be accessed on the date
the service is provided, since the recipients eligibility is subject to change. Payment will not be
made for ineligible recipients.
The purpose of EVS is to provide the most current information available regarding a
recipients MA eligibility and scope of coverage. EVS will also provide details on the recipients
third party resources, managed care plan, and/or lock-in information, when applicable.
For additional information about EVS, please reference Quick Tip #11 in the link below:
http://www.dpw.state.pa.us/publications/forproviders/QuickTips/index.htm
Please see Appendices (D)(5) and (D)(6) for information on participant Medical Assistance
cards and benefits.
Billing Guidelines
Invoicing Options
Providers can submit claims to DPW via the 837 Institutional/UB-04 Claim Form or through
electronic media claims (EMC).
Electronic Media Claims (EMC)
PA PROMISe can accept billing submitted on magnetic tape, diskette, compact disk (CD),
through Direct Connect, through a Clearinghouse, Bulletin Board via Personal Computer (PC)
modem dial up, file transfer protocol (FTP), or modem-to-modem. For more information on
these invoicing options, please contact:
HP/PA PROMISe
225 Grandview Avenue, 1st Floor
Mail Stop A-20
Camp Hill, PA 17011
Telephone: 800-248-2152 (in-state only)
717-975-4100 (local)
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For information on the submitting claims electronically via the Internet, please refer to:
PROMISe Provider Handbooks and Billing Guides at the link below:
http://www.dpw.state.pa.us/publications/forproviders/promiseproviderhandbooksandbillingguid
es/index.htm
To access the PROMISe website for other information such as PROMISe training, use
the link below:
https://promise.dpw.state.pa.us/portal/Default.aspx?alias=promise.dpw.state.pa.us/portal/provi
der
Electronic Media Claims
For claim forms submitted via any electronic media that require an attachment or attachments,
you will need to obtain a Batch Cover Letter and an Attachment Control Number (ACN). Batch
Cover Letters and ACNs can be obtained via the DPW PROMISe Internet site
http://promise.dpw.state.pa.us, from the Provider Claim Attachment Control Window. For more
information on accessing the Provider Claim Attachment Control Window, refer to the Provider
Internet Users Manual found in Appendix C of the 837 Professional/CMS-1500 Claim Form
Handbook.
Providers submitting claims electronically will receive an electronic Remittance Advice (RA) in
the Health Care Payment and Remittance Advices (ANSI 835) format as well as a hardcopy
RA Statement after each weekly cycle in which the providers claim forms were processed.
For questions concerning the information contained on the RA Statement, access Section 8
(Remittance Advice). If additional assistance is needed, contact the appropriate Provider
Inquiry Unit in DPW at:
http://www.dpw.state.pa.us/helpfultelephonenumbers/contactinformationhelpformaproviders/in
dex.htm
Please Note: For tape-to-tape billers, the enrolled and approved Service Bureau (or
the provider if producing his/her own magnetic tape) will receive a reconciliation tape
after each weekly cycle in which claim forms were processed.
Payment Process
PA PROMISeTM processes financial information up to the point of payment. PA PROMISe
does not generate actual payments to providers. The payment process is managed by the
Commonwealth Treasury Departments Automated Bookkeeping System (TABS). PA
PROMISe requests payments to be made by generating a file of payments that is sent to
TABS. From there, payments can take the form of checks or Electronic Funds Transfers
(EFTs). PA PROMISe will produce a Remittance Advice (RA) Statement for each provider
who has had claims adjudicated and/or financial transactions processed during the payment
cycle.
Providers have the option of receiving a check via the mail from the Treasury Department or
they may utilize a direct deposit service known as the Automated Clearinghouse (ACH)
Program. This service decreases the turnaround time for payment and reduces administrative
costs. ACH reduces the time it takes to receive payment from DPW. Provider payments are
deposited via electronic media to the bank account of the providers choice. ACH is an
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efficient and cost effective means of enhancing practice management accounts receivable
procedures. ACH enrollment information can be obtained from DPWs website at:
http://www.dpw.state.pa.us/provider/doingbusinesswithdpw/electronicfundstransferdirectdepos
itinformation
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entered on the original claim being adjusted. For claim line information, copy the
corresponding information from the original claim for all items, which remain unchanged.
Where a correction is necessary, enter the correct information.
Claim adjustments may be made to more than one claim line on a single claim adjustment.
All claim lines associated with the original claim processed will be assigned a new,
adjusted Internal Control Number (ICN). Consequently, an adjustment may be made to
only one claim line where their lines had originally been submitted. Although only one of
the claim lines may be adjusted, all claim lines will be assigned a new, adjusted ICN. If
adjusting multiple claim lines from a single claim, again, all claim lines associated with the
original claim will receive a new, adjusted ICN. If a claim adjustment on a previously
adjusted claim needs to be submitted, it must use the last approved ICN to adjust another
claim line on a previously adjusted claim.
Remittance Advice
(See Appendix (D)(10) for sample)
Reference Quick Tip #07 at:
http://www.dpw.state.pa.us/publications/forproviders/QuickTips/index.htm.
The Remittance Advice (RA) Statement explains the actions taken and the status of claims
and claim adjustments processed by DPW during a daily cycle. The processing date on the
RA statement is the computer processing date for the cycle. Checks corresponding to each
cycle are mailed separately by the Treasury Department.
The first page of the RA is used as a mailing label and contains the Address where the RA is
being sent. This is followed by the Detail page(s) that list all of the invoices processed during
the PA PROMISe daily cycle. The next page is a Summary of activity from the detail
page(s). Finally, the last page(s) is the Explanation of Edits Set This Cycle page(s).
Remittance Advice Address Page
The RA Address Page contains the address where the RA Statement is to be mailed and is
used as a mailing label.
Providers may also find a Remittance Advice (RA) Alert on this page. From time to time, DPW
may need to disseminate information quickly to the provider community. Consequently, an
alert may be contained on the Address page of the RA Statement or in the form of an insert
contained within the RA Statement.
Remittance Advice Detail Page
The detail pages of the RA statement contain information about the invoices and claim
adjustments processed during the daily cycle.
Claim form information contained on the detail pages is arranged alphabetically by recipient
last name. If there is more than one provider service location code, claims will be returned
on separate RA Statements as determined by each service location.
Third Party Liability, Other Insurance and Medicare
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Medical Assistance is considered the payer of last resort. All other insurance coverage
must be exhausted before billing MA. The MA Program is responsible only for payment of the
unsatisfied portion of the bill, up to the maximum allowable MA fee for the service as listed in
the Medical Assistance Program Fee Schedule.
It is your responsibility to ask if the recipient has other coverage not identified through the EVS
(i.e., Worker's Compensation, Medicare, etc.)
If other insurance coverage exists, you must bill it first. You would only bill MA for unsatisfied
deductible or coinsurance amounts or if the payment you receive from the other insurance
coverage is less than the MA fee for that service. In either case, MA will limit its payment to
the MA fee for that service. When billing DPW after billing the other insurance, indicate the
resource on the invoice as indicated in the detailed invoice instructions.
When a recipient is eligible for both Medicare and MA benefits, the Medicare program must be
billed first if the service is covered by Medicare. Payment will be made by MA for the Medicare
Part B deductible and coinsurance up to the MA fee.
DPW does not require that you attach insurance statements to the invoice. However, the
statements must be maintained in your files and available upon request.
Duplicate copies of claims forms may be released by providers to: recipients, a recipients
personal representative who can consent to medical treatment, or an attorney or insurer with a
signed authorization request. The provider shall submit a copy of the invoice and the request
to the following address:
Department of Public Welfare
TPL - Casualty Unit
P.O. Box 8486
Harrisburg, PA 17105-8486
(717) 772-6604
The TPL Casualty Unit will follow-up and take appropriate action for recovery of any MA
payment recouped in a settlement action.
This procedure MUST be followed by ALL providers enrolled in the MA Program for ALL
requests for payment information about MA recipients. This includes recipients enrolled in an
MCO.
Third Party Resource Identification and Recovery Procedures
When DPW discovers a potential third party resource after a claim was paid, a notification
letter will be sent to the provider with detailed claim/resource billing information and an
explanation of scheduled claim adjustment activity. Providers must submit documentation
relevant to the claim within the time limit specified in the recovery notification. If difficulty is
experienced in dealing with the third party, notify DPW at the address indicated on the
recovery notice within 30 days of the deadline for resubmission. If the provider fails to respond
within the time limit, the funds will be administratively recovered and the claims cannot be
resubmitted for payment.
Medical Assistance Managed Care
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Providers have the ability to search, view, download, and print service authorization
notices, which include the number of units the provider is authorized to provide to the
participant.
The ability to view service authorization notices will help facilitate and resolve billing and
claims issues for providers.
All claims submitted through PROMISe are checked against the HCSIS system to
ensure that the service and units are available.
By accessing PASA and reconciling their records with the information in HCSIS,
providers can minimize the number of billing issues and denials.
PASA is a valuable tool that facilitates communication with service coordinators. Since
service coordinators are responsible for entering service authorizations and tracking ISPs,
they can quickly and easily coordinate services with providers by referring them to the
PASA.
Important Note for SCs: Service coordinators need to make sure that the Direct Service
providers they are working with complete both the Provider Sign-Up form and the DPW User
Agreement. In order to access the forms, please contact the HCSIS Help Desk by phone at:
1-866-444-1264 or by email at c-hhcsishd@state.pa.us.
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Chapter 5
QUALITY MANAGEMENT
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Chapter 5
QUALITY MANAGEMENT
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QMET State and Regional Contact Information- Contact information for the QMET Statewide
Coordinator and each QMET Regional Program Specialists.
Waiver Standards Tool - The attached Waiver Standards document reflects each
measurement reviewed by the QMET. Each standard correlates to a specific point in the
waiver.
Fiscal/Employer Agent (F/EA) Financial Management Services (FMS) Provider Standards OLTL's Fiscal Employer Agent (F/EA) Standards
Home and Community Based Waivers
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Additional information about MA Fraud and Abuse can be found in the Fraud and Abuse
section of this website.
In addition, the federal government has developed a set of frequently asked questions to
assist providers who receive audit requests:
Medicaid Integrity Program (MIP), Provider Audits - Frequently Asked Questions.
Please reference OLTL Bulletin 05-11-04 , Program Fraud & Financial Abuse in Office of
Long Term Living MA Home and Community-Based Service (HCBS) Programs.
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Chapter 6
SYSTEMS
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Chapter 6
SYSTEMS
Program Overview:
Within OLTL, the following programs use HCSIS:
Each of these programs has different policies and procedures that dictate how eligibility decisions
are made. As OLTL standardizes the home and community-based service system, there is a need
to standardize the participant records maintained in HCSIS.
The OLTL uses information from HCSIS to meet the Waiver Assurances mandated by the Centers
for Medicare and Medicaid Services (CMS). The assurances were put into place by Congress to
address the unique challenges of assuring the quality of services delivered to vulnerable persons
living in their community. The documentation and information required in HCSIS supports the
assurances and ensures that our programs continue to be supported. Service coordinators and
their supervisors play an integral role in ensuring that the information in HCSIS is consistent,
complete and correct. Resource information on the development of individual service plans is
accessible through the Learning Management System (LMS) in HCSIS.
HCSIS is available on the Internet at: https://www.hcsis.state.pa.us.
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While there, click on the Learning Management System icon and look for this LMS sign-on
screen to access tip sheets within HCSIS.
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Record incidents
Investigate incidents
Track and trend incident data for quality improvement activities
OLTL will continue to use HCSIS, as they do today, for participant, provider, plan and case
management. EIM integrates with HCSIS to gather individual and provider information for use
in incident reports.
Training Materials
http://www.dpw.state.pa.us/dpworganization/officeoflongtermliving/eim/providers/index.htm
EIM Provider User Training Materials
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citizens served. The statewide implementation of SAMS has instituted common terms and
standards statewide. In addition to providing individual client tracking, SAMS provides
functionality to support the administration and management of the AAAs.
Currently, an interface exists between HCSIS and SAMS that allows for the payment of claims
for services to clients of the Department of Aging covered under the applicable waiver
program. This interface consists of a nightly SAMS extract that provides consumer (a.k.a.
client) and service plan data to be entered to HCSIS and subsequently used by PROMISe in
the payment of claims.
SAMS stores information from the collaboration between the participant and the service
coordinator. Storing the plan electronically in SAMS affords service coordinators quick
accessibility to plan information. Participant service plans and the process of developing
service plans is being improved as specified in the work plan.
The service coordinator gathers information on an ongoing process to assure the ISP reflects
the participants needs. Revisions are discussed with the participant and entered into SAMS
and the updated service information is shared with the participant and service providers.
Changes that are made to service plan information in SAMS are transferred to HCSIS on a
daily basis through a nightly upload.
Resource material is available for SAMS users through the Long Term Care Training Institute
(LTLTI): http://www.ltltrainingpa.org/.
SAMS is a web-based system that can be accessed through the Internet. In order to access
SAMS, each user needs: 1) a digital security certificate installed on the individuals computer;
2) an AGENET account established and; 3) a SAMS user account established. To initiate the
process to access SAMS, contact the Section Chief in the Division of Data Collection and
Reporting at the Department of Aging at 717-783-0178.
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the on-line transactions are turned off for the day and hundreds more programs are executed
in batch mode to issue benefits, create history, and pass data on to other systems.
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APPENDICES
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Appendix (A)(1)
CHAPTER 1101. GENERAL PROVISIONS
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Appendix (A)(2)
[55 PA.CODE CH. 52]
LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES
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Appendix (A)(3)
CHAPTER 611. HOME CARE AGENCIES AND HOME CARE REGISTRIES
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Appendix (A)(4)
CHAPTER 41. MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES
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Appendix (A)(5)
CHAPTER 1150. MA PROGRAM PAYMENT POLICIES
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Appendix (B)(1)
Bulletin List (OLTL)
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Appendix (B)(2)
FAQs
Frequently Asked Questions regarding the Long-Term Living Home and Community-Based
Services regulation (55 Pa.Code Chapter 52) can be found at the following link:
http://www.dpw.state.pa.us/dpworganization/officeoflongtermliving/providers/index.htm
Questions are based on comments received from providers.
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Appendix (B)(3)
HCBS Eligibility/Ineligibility/Change Form (PA 1768)
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Appendix (C)(1)
OLTL Individual Service Plan
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Appendix (C)(2)
New Participant Web Portal Referral CHECK LIST
NOTE: This form is to be utilized only when the PPL Web Portal is unavailable:
https://fms2.publicpartnerships.com/PPLPortal/Login.aspx
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Appendix (C)(3)
New Participant F/EA FMS Interim Referral Form
NOTE: This form is to be utilized only when the PPL Web Portal is unavailable:
https://fms2.publicpartnerships.com/PPLPortal/Login.aspx
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Appendix (C)(4)
Freedom of Choice Form
COMMONWEALTH OF PENNSYLVANIA
OFFICE OF LONG-TERM LIVING
Bureau of Participant Operations
FREEDOM OF CHOICE FORM
I have been informed that I may be eligible for home and community-based services
(HCBS).
I have been informed what services I may be able to get and my rights and responsibilities
under each service.
Based on the information that has been presented to me, I want to [check one]:
1. [
] Receive no services
If I choose to receive HCBS, I know that I have the right to pick the agency that will provide
each of my HCBS services from among the enrolled Medicaid HCBS providers in my area.
Form Distribution
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I know that the Service Coordination agency will review the list of available HCBS
providers with me.
__________________________________________________________________
Applicant/Representatives Signature
Date
__________________________________________________________________
Service Coordinator/IEB/AAA Signature
Date
Form Distribution
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Appendix (C)(5)
Service Provider Choice Form
COMMONWEALTH OF PENNSYLVANIA
OFFICE OF LONG TERM LIVING
Bureau of Participant Operations
SERVICE PROVIDER CHOICE FORM
Name (Last, First, Middle):
Address:
County:
Before you choose who will be providing your home and community-based
services, we have to tell you that:
1.
You have the right to decide who will give you the services listed in your
Individual Service Plan as long as they are enrolled in the program and
qualified to provide you those kinds of services.
2.
You have the right to talk to or interview someone from any provider
before making your choice of providers. Interviewing providers can be a
long process and might result in a delay of services.
3.
4.
5.
You may choose more than one service provider to give you the same
kind of service as needed.
6.
7.
You can change your mind about who gives you services at any time by
telling your Service Coordinator
8.
If there are issues you have been unable to resolve or it would be hard
discussing them with your Service Coordinator, you may call the OLTL
Quality Assurance Helpline at 1-800-757-5042. There is no charge for
calling this number.
Form Distribution
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Please acknowledge the following statements by checking each box and signing at the
bottom of the form:
I understand that I may talk to someone from any services provider before making
my decision in selecting a provider.
I have freely chosen the provider for each service listed in my Individual Service
Plan on the back of this form.
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If you have someone who is helping you or supporting with this discussion, please ask
that person to sign to show that they have taken part by helping you.
Signature
Date
Form Distribution
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County:
SELECTED PROVIDER(S)
Form Distribution
Ranking
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Appendix (C)(6)
OLTL Service Authorization Form (MA 560)
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Appendix (C)(7)
Notice of Service Determination and the Right to Appeal (MA 561)
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Appendix (C)(8)
Bureau of Hearings and Appeals (BHA) Agency Appeal Cover Sheet
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Appendix (C)(9)
Decision to Withdraw an Appeal Request (MA 562)
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Appendix (C)(10)
PROMISe Provider Enrollment Base Application CHECK LIST
PROMISe Provider Enrollment Base Application (must contain original signatures)
Outpatient Provider Agreement (must contain original signatures)
Ownership or Control Interest Pages
Legal Entity Verification Document (IRS-generated form with FEIN, business name, and address)
Articles of Incorporation (if applicable)
Partnership Agreement (if applicable)
Copy of Pennsylvania Department of Health Home Care License (if applicable)
Copy of Pennsylvania Department of Aging Adult Day Care License (if applicable)
Copy of Pennsylvania State Certification(s) or license (if applicable)
Most Recent Tax Return, as applicable
Most Recent Monthly Balance Sheet or Business Plan
Most Recent Audit or Financial Review (if applicable)
Provider Enrollment Information Form: Aging - CommCare/Independence/OBRA - ACW/150
Qualifications of the Executive Director and/or the Program Director (Include copies of their diplomas
and resume)
OLTL-HCBS Waiver Agreement
Proof of Insurances
General Liability
Workers Compensation
Professional Liability (if app.)
Policy Compliances
ADA Compliance Policy
Non-discrimination Policy
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Please Note: OLTL must receive all documents in the checklist in order to process your enrollment
application. The enrollment process may take several weeks to complete.
If you should have any questions, please contact the Provider Support Call Center at 1-800-932-0939
or send an email to RA-HCBSEnProv@pa.gov .
Please return all completed documents including the checklist to:
Office of Long-Term Living
Bureau of Quality and Provider Management
Certification and Enrollment Section
th
555 Walnut Street, 6 Floor
P.O. BOX 8025
Harrisburg PA 17106-8025
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Appendix (C)(11)
PROMISe Provider Enrollment Base Application
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100
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101
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Appendix (C)(12)
HCBS Waiver Provider Agreement
102
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103
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Appendix (C)(13)
Provider Enrollment Form: COMMCARE, Independence & OBRA
104
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105
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Appendix (C)(14)
Provider Enrollment Form: Aging Waiver
106
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107
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Appendix (C)(15)
Provider Enrollment Form: Attendant Care & Act 150
108
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Appendix (C)(16)
Provider Enrollment Form: Service Coordination
109
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Appendix (C)(17)
Provider Enrollment Form: OHCDS
110
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111
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Appendix (C)(18)
Provider Disclosure Form
112
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Appendix (C)(19)
Ordering Forms
The following sections detail the various forms providers may need when billing PA
PROMISe and the addresses, telephone numbers, and website, when available, for
obtaining these forms.
Medical Assistance Forms
Providers may order MA forms via the MA 300X (MA Provider Order Form) or by
accessing DPWs website site at:
http://www.dpw.state.pa.us/dpwassets/maforms/index.htm
For providers who do not have access to the Internet, the MA 300X can be ordered
directly from DPWs printing contractor:
Department of Public Welfare
MA Forms Contractor
P.O. Box 60749
Harrisburg, PA 17106-0749
Additionally, providers can obtain an order form by submitting a request for the MA 300X,
in writing, to:
Department of Public Welfare
Office of Medical Assistance Programs
Division of Operations
P.O. Box 8050
Harrisburg, PA 17105
You can expect to receive your forms within two weeks from the time you submit your
order. This quick turnaround time on delivery is designed to eliminate the need for most
emergencies. You should keep a three to six month supply of extra forms, including order
forms, on hand and plan your ordering well in advance of exhausting your supply.
The MA 300X can be typed or handwritten. Photocopies and/or carbon copies of the MA
300X are not acceptable. Orders must be placed on an original MA 300X.
The MA 300X is continually being revised as forms are added or deleted. Therefore, you
may not always have the most current version of the MA 300X form from which to order.
You need to be cognizant of MA Bulletins and manual releases for information on new,
revised, or obsolete forms so that you can place your requisitions correctly. If a new MA
form is not on your version of the MA 300X, you are permitted to add the form to the MA
300X.
Please note that forms specific to services administered by the Office of Mental Health and
Substance Abuse Services may not be available for ordering using the MA 300. Please
contact OMHSAS via email at HC-Services@pa.gov or you may call OMHSAS Provider
Inquiry at 800-433-4459.
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Contact the US Government Printing Office at (202) 512-1800 or your local Medicare
carrier. You may access the website at http://bookstore.gpo.gov. For a list of local
Medicare carriers in your state, including their telephone number, please go to the
Medicare Regional Homepage.
You contact the American Medical Association Unified Service Center at 800-6218335.
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Appendix (D)(1)
County Assistance Office (CAO) Contact List
See CAO Contact List at:
http://www.dpw.state.pa.us/findfacilsandlocs/countyassistanceofficecontactinformation/index.h
tm
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Appendix (D)(2)
Area Agencies On Aging Map
http://www.portal.state.pa.us/portal/server.pt?open=514&objID=616534&mode=2
Looking for information on what programs and services are available in your community? The
best place to start is with your local Area Agency on Aging. Click on your county of residence
in the list below for specific Area Agencies on Aging listings.
01. Adams
02. Allegheny
03. Armstrong
04. Beaver
05. Bedford
06. Berks
07. Blair
08. Bradford
09. Bucks
10. Butler
11. Cambria
12. Cameron
13. Carbon
14. Centre
15. Chester
16. Clarion
17. Clearfield
18. Clinton
19. Columbia
20. Crawford
21. Cumberland
22. Dauphin
23. Delaware
24. Elk
25. Erie
26. Fayette
27. Forest
28. Franklin
29. Fulton
30. Greene
31. Huntingdon
32. Indiana
33. Jefferson
34. Juniata
35. Lackawanna
36. Lancaster
37. Lawrence
38. Lebanon
39. Lehigh
40. Luzerne
41. Lycoming
42. McKean
43. Mercer
44. Mifflin
45. Monroe
46. Montgomery
47. Montour
48. Northampton
49. Northumberland
50. Perry
51. Philadelphia
52. Pike
53. Potter
54. Schuylkill
55. Snyder
56. Somerset
57. Sullivan
58. Susquehanna
59. Tioga
60. Union
61. Venango
62. Warren
63. Washington
64. Wayne
65. Westmoreland
66. Wyoming
67. York
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Appendix (D)(3)
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) became public law on August
21, 1996. It is a federal bi-partisan law based on the Kennedy-Kassebaum bill. The
Department of Health and Human Services assigned the Centers for Medicare & Medicaid
Services (CMS) the task of implementing HIPAA. The primary goal of the law was to make it
easier for people to keep health insurance, and help the industry control administrative costs.
HIPAA is divided into five Titles or sections. Title I is Portability and has been fully
implemented. Portability allows individuals to carry their health insurance from one job to
another so that they do not have a lapse in coverage. It also restricts health plans from
imposing pre-existing condition limitations on individuals who switch from one health plan to
another.
Title II is called Administrative Simplification. Title II is designed to:
Reduce health care fraud and abuse;
Guarantee security and privacy of health information;
Enforce standards for health information and transactions; and
Reduce the cost of healthcare by standardizing the way the industry communicates
information.
Titles III, IV, and V have not yet been defined.
The main benefit of HIPAA is standardization. HIPAA requires the adoption of industry-wide
standards for administrative health care transactions; national code sets; and privacy
protections. Standards have also been developed for unique identifiers for providers, health
plans and employers; security measures; and electronic signatures.
HIPAA Privacy
The HIPAA Privacy Rule became effective on April 14, 2001, and was amended on August
14, 2002. It creates national standards to protect medical records and other protected health
information (PHI) and sets a minimum standard of safeguards of PHI.
The regulations impact covered entities that are health care plans, health care clearinghouses
and health care providers. Most covered entities, except for small health plans, must comply
with the requirements by April 14, 2003. DPW performs functions as a health care plan and
health care provider. Any entity having access to PHI must do an analysis to determine
whether it is a covered entity and, as such, subject to the HIPAA Privacy Regulations.
Requirements
Generally, the HIPAA Privacy Rule prohibits disclosure of PHI except in accordance with the
regulations. All organizations which have access to PHI must do an analysis to determine
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whether or not it is a covered entity. The regulations define and limit the circumstances under
which covered entities may use or disclose PHI to others. Permissible uses under the rules
include three categories:
1. Use and disclosure for treatment, payment and healthcare operations;
2. Use and disclosure with individual authorization; and
3. Use and disclosure without authorization for specified purposes.
The HIPAA Privacy Regulations require Covered Entities to:
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Header: This notice describes how medical information about you may be used and
how you can get access to this information. Please review it carefully.
A description, including at least one example, of the types of uses and disclosures the
covered entity may make for treatment, payment or health care operations.
A description of each of the other purposes for which the covered entity is required or
permitted to use or disclose individually identifiable health information without consent
or authorization.
If appropriate, a statement that the covered entity will contact the individual to provide
information about health-related benefits or services.
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A statement informing individuals how they may complain about alleged violations of
the privacy regulations.
Enforcement
DPW is not responsible for the enforcement of the HIPAA privacy requirements. This
responsibility lies with the U.S. Department of Health and Human Services, Office for Civil
Rights (OCR). The enforcement activities of OCR will involve:
Seeking civil monetary penalties and making referrals for criminal prosecution
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129
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Appendix (D)(4)
Eligibility Verification System Quick Tips
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131
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Appendix (D)(5)
Recipient Benefits
580.6 Pennsylvania EBT ACCESS Card
The Pennsylvania EBT ACCESS card is an industry-standard plastic card with a magnetic
stripe giving recipients access to cash assistance, Supplemental Nutrition Assistance Program
(SNAP) benefits, or Medical Assistance benefits (or any combination of them). Recipients get
SNAP benefits electronically through point-of-sale (POS) terminals in authorized food stores.
They can get cash assistance through POS terminals and automated teller machines (ATMs).
Recipients can verify their eligibility for Medical Assistance through the online Eligibility
Verification System (EVS).
For more information on the ACCESS Card please reference Chapter 380 of the Medical
Assistance Eligibility Handbook or Chapter 580.6 of the SNAP Handbook at the
following links:
http://oimmanuals/bop/Robo/MA/index.htm
http://oimmanuals/bop/Robo/SNAP/index.htm
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Appendix (D)(6)
Utilizing Provider Resources
Resource
Aging and
Disability
Resource
Centers
(ADRCs)
Area Agencies
on Aging
(AAAs)
COMPASS
County
Assistance
Offices (CAOs)
Description
Contact Information
COMPASS site:
https://www.humanservices.state.p
a.us/compass.web/CMHOM.aspx
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Resource
Description
Contact Information
DPW, Medical
Assistance
(MA), Health
Choices, and
Access Plus
Enterprise
Incident
Management
System (EIM)
Email:
RA-OLTL_EIMimplement@pa.gov
Website:
https://www.hcsis.state.pa.us
Fraud and
abuse resource
DPW website:
www.dpw.state.pa.us
Medicaid/MA, Health Choices, and
Access Plus website:
www.dpw.state.pa.us/foradults/he
althcaremedicalassistance/index.h
tm
Phone: 1-866-444-1264
Fax: (717) 540-0960
Email: c-hhcsishd@state.pa.us
LIFE Program
Information &
Provider List
Website:
http://www.dpw.state.pa.us/fordisa
bilityservices/alternativestonursing
homes/lifelivingindependenceforth
eelderly/index.htm
Long Term
Living Training
Institute (LTLTI)
of PA
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Resource
Description
Contact Information
OLTL Bureau of
Participant
Operations
OLTL Bureau of
Quality and
Provider
Management
Call Center
OLTL Bureau of
Quality and
Provider
Management
Email: ra-hcbsenprov@pa.gov
OLTL
Participant
Helpline
PA Centers for
Independent
Living
PA Code
Website: www.pacode.com
PA Independent
Enrollment
Broker
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Resource
Description
Contact Information
PROMISe
Resources
Bureau of
Quality and
Provider
Management
Website:
http://www.dpw.state.pa.us/provid
er/doingbusinesswithdpw/quality/q
pm/index.htm
Waiver
descriptions
Website:
http://www.dpw.state.pa.us/foradul
ts/healthcaremedicalassistance/su
pportserviceswaivers/index.htm
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Appendix (D)(7)
Rate Chart Fee Schedule Rates
See OLTL Billing Instructions Bulletin at:
http://www.dpw.state.pa.us/dpworganization/officeoflongtermliving/providers/index.htm
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Appendix (D)(8)
Rate Regions (4)
Region 2
Region 3
Region 4
Allegheny
Bedford
Adams
Bucks
Armstrong
Blair
Berks
Chester
Beaver
Bradford
Carbon
Delaware
Fayette
Butler
Cumberland
Montgomery
Greene
Cambria
Dauphin
Philadelphia
Washington
Cameron
Franklin
Westmoreland
Centre
Fulton
Clarion
Huntingdon
Clearfield
Juniata
Clinton
Lancaster
Columbia
Lebanon
Crawford
Lehigh
Elk
Northampton
Erie
Perry
Forest
Schuylkill
Indiana
York
Jefferson
Lackawanna
Lawrence
Luzerne
Lycoming
McKean
Mercer
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Mifflin
Monroe
Montour
Northumberland
Pike
Potter
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Wayne
Wyoming
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Appendix (D)(9)
Crosswalk
Aging Waiver
Old Procedure Code and Service Name
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Therapy-Assist.
T2025 GP-Physical Therapy
W1700-Personal Care
W1701-Personal Care Shift
W1793-Personal Assistance Service
(agency model)
W1729-Home Support housekeeping
W1792-PAS (Consumer)
W1702-Respite Services
W1703-Respite Shift
S5151-Respite Per Diem
T1005-Respite (Agency)
or
S5150-Respite (Consumer)
W1011-Service Coordination
H0004-Thera&Couns Svcs (Counseling
Svcs)
W7009-Accessibility Adaptations(<$6000)
or
W7008-Accessibility Adaptations(>$6000)
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W6110-Non-medical Transportation
W1900-Participant-Directed Community
Supports
W1900-Participant-Directed Community
Supports
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W1723-Companion Services
W1732-Initial Extermination
W1733-Follow-up Extermination
W1792-PAS (Consumer)
W1792-PAS (Consumer)
W1794-Service Coordination
W1011-Service Coordination
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W1900-Participant-Directed Community
Supports
W1900-Participant-Directed Community
Supports
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Services My Way
Services My Way
W1792-PAS (Consumer)
W1792-PAS (Consumer)
W1794-Service Coordination
W1011-Service Coordination
COMMCARE Waiver
Old Procedure Code and Service Name
97537-Community Integration
97537-Community Integration
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W1793-PAS (Agency)
S5120-PAS (Chore Svcs)
W6043 UJ-PAS (Night Supervision, Agency,
Weekdays)
W6043 TV-PAS (Night Supervision, Agency,
Weekends)
W1793-PAS (Agency)
W1792-PAS (Consumer)
W6042 UJ-PAS (Night Supervision,
Consumer, Weekdays)
W6042 TV-PAS (Night Supervision,
Consumer, Weekends)
W1792-PAS (Consumer)
W6107-Prevocational Services
W6107-Prevocational Services
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T1005-Respite (Agency)
T1005-Respite (Agency)
S5150-Respite (Consumer)
S5150-Respite (Consumer)
W1877-Service Coordination
W1011-Service Coordination
W6106-Supported Employment
W6106-Supported Employment
W7008-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods<$100)
W7008-Accessibility Adaptations(<$6000)
W7009-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods>$100)
W7009-Accessibility Adaptations(>$6000)
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Fees)
Fees)
W6110-Non-medical Transportation
W6110-Non-medical Transportation
Independence Waiver
Old Procedure Code and Service Name
97537-Community Integration
97537 TF-Community Integration (Peer
Counselor)
97537 TG-Community Integration (Skills
Trainer)
97537-Community Integration
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W1793-PAS (Agency)
W1793-PAS (Agency)
W1792-PAS (Consumer)
W1792-PAS (Consumer)
T1005-Respite (Agency)
T1005-Respite (Agency)
S5150-Respite (Consumer)
S5150-Respite (Consumer)
W1877-Service Coordination
W1011-Service Coordination
W6106-Supported Employment
W6106-Supported Employment
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W7008-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods<$100)
W7008-Accessibility Adaptations(<$6000)
W7009-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods>$100)
W7009-Accessibility Adaptations(>$6000)
W6110-Non-medical Transportation
W6110-Non-medical Transportation
W7033-Non-Medical Transportation
(Additional)
W7340-Intake Supports Coordination
W6105-Education Svcs
T2038-Community Transition Svcs
T1005 TT-Respite (CSLA)
150
January 2014
OBRA Waiver
Old Procedure Code and Service Name
97537-Community Integration
97537 TF-Community Integration (Peer
Counselor)
97537 TG-Community Integration (Skills
Trainer)
97537-Community Integration
W1793-PAS (Agency)
W1793-PAS (Agency)
W1792-PAS (Consumer)
W1792-PAS (Consumer)
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T1005-Respite (Agency)
T1005-Respite (Agency)
S5150-Respite (Consumer)
S5150-Respite (Consumer)
W6107-Prevocational Services
W6107-Prevocational Services
T1005-Respite (Agency)
T1005-Respite (Agency)
S5150-Respite (Consumer)
S5150-Respite (Consumer)
W6100-Service Coordination
W1011-Service Coordination
W6106-Supported Employment
W6106-Supported Employment
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W7008-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods<$100)
W7008-Accessibility Adaptations(<$6000)
W7009-AccessAdapt, Equip,
Tech&MedSuppl(EnvMods>$100)
W7009-Accessibility Adaptations(>$6000)
W6110-Non-medical Transportation
W6110-Non-medical Transportation
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Appendix (D)(10)
Remittance Advice Sample
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155
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Appendix (E)
Glossary
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Fee schedule serviceA service paid based on the MA Program fee schedule rates
established by the Department.
Financial management servicesA service which provides payroll, invoice processing
and payment, fiscal reporting services, employer orientation, skills training and other
fiscal-related services to participants choosing to exercise employer or participantdirected budget authority.
Financial reviewA review of billing records against provider documentation to ensure
services were provided in the type, scope, amount, duration and frequency as
required by the participants service plan and to ensure that a billing for a service
rendered by a provider is accurate.
FindingAn identified violation of the following:
(i) This chapter.
(ii) The MA provider agreement, including the waiver addendum.
(iii) Chapter 1101 (relating to general provisions).
(iv) The approved applicable waiver, including approved waiver amendments.
(v) A State or Federal requirement.
HCBSHome and community-based servicesServices offered as part of a
Federally-approved MA waiver or Act 150 program.
IADLInstrumental activities of daily livingThe term includes the following activities
when done on behalf of a participant:
(i) Laundry.
(ii) Shopping.
(iii) Securing and using transportation.
(iv) Using a telephone.
(v) Making and keeping appointments.
(vi) Caring for personal possessions.
(vii) Writing correspondence.
(viii) Using a prosthetic device.
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(ix) Housekeeping.
ICF/ORCIntermediate care facility/other related conditions.
Independence waiverA Federally-approved 1915(c) waiver under section 1915(c) of
the Social Security Act that authorizes services to participants 18 years of age and
older but under 60 years of age with physical disabilities.
Individualized back-up planA plan which outlines the steps to be taken by the
provider and participant to ensure that services are delivered to the participant in a
situation where routine service delivery is interrupted.
Informal community supportsServices provided by a family member, friend,
community organization or other entity for which funding is not provided by the
Department.
LEIEList of Excluded Individuals and EntitiesA database maintained by the United
States Department of Health and Human Services, Office of the Inspector General,
that identifies individuals or entities that have been excluded Nationwide from
participation in a Federal health care program.
Level of care re-evaluationA redetermination of a participants clinical eligibility
under a waiver or the Act 150 program.
MAMedical Assistance.
MA provider agreementAn enrollment agreement signed by the provider which
establishes requirements relating to the provision of services.
MedicaidMA provided under a State Plan approved by the United States
Department of Health and Human Services under Title XIX of the Social Security Act
(42 U.S.C.A. 1396a).
Medicaid State PlanA plan to provide MA developed by the Department and
approved by the United States Department of Health and Human Services under Title
XIX of the Social Security Act which serves as the basis for Federal financial
participation in the program.
MedicheckA Departmental list identifying providers, individuals and other entities
precluded from participation in the Commonwealths MA Program.
MonitoringA review of a providers compliance.
Nursing facility
(i) A long-term care facility that is:
(A) Licensed by the Department of Health.
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161
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Appendix (F)
Acronym List
AAA
ACN
ADL
BPI
CAO
CIS
CMS
COMMCARE
DCW
DME
DPPC
DPR
DPW
EIM
EVS
FFS
FMS
HCBS
HCSIS
HIPAA
HIPP
IEB
ICF
ISP
LEIE
LEP
LIFE
LOCA
MA
MCO
MFP
NF
NHT
OBRA
OHCDS
OLTL
PACE
PASA
PERS
PROMISe
QMET
QPM
RA
RFA
SAMS
SCE
SMW
TBI
TPL
VF/EA
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